Vancomycin for prophylaxis against sepsis in preterm neonates

Nosocomial, late onset sepsis occurs in up to 50% of infants of less than 1000gm at birth. The commonest organism isolated is coagulase negative staphylococcus (CoNS). A number of studies have evaluated the efficacy or prophylactic low dose vancomycin given either as a continuous infusion added to the infant's hyperalimentation fluid or by intermittent intravenous administration and these studies in very low birth weight infants are the subject of this review.

To evaluate the safety and efficacy of vancomycin prophylaxis for the prevention of late-onset sepsis, coagulase negative staphylococcal sepsis, mortality, and effects on length of stay, total vancomycin exposure, evidence of vancomycin toxicity, and the development of vancomycin resistant organisms in the preterm neonate.

Searches were made of Medline, (MeSH terms: Vancomycin and Sepsis; limits: age groups, newborn infants), HealthStar and EMBase, electronic abstracts, personal files and conference proceedings.

Randomized controlled trials which compared the incidence of sepsis and mortality in preterm neonates receiving vancomycin prophylaxis versus a control group receiving no prophylaxis.

Data regarding clinical outcomes including the overall incidence of sepsis, the incidence of coagulase negative staphylococcal sepsis, mortality, length of stay, total vancomycin exposure, evidence of vancomycin toxicity, and the development of vancomycin resistant organisms were excerpted from previous clinical trials. Data analysis was done in accordance with the standards of the Cochrane Neonatal Review Group.

The administration of prophylactic vancomycin reduced the incidence of both total neonatal nosocomial sepsis and coagulase negative staphylococcal sepsis in eligible preterm infants. Mortality, length of stay, and evidence of vancomycin toxicity were not significantly different between the two groups. There was insufficient evidence to ascertain the risks of development of vancomycin resistant organisms in the nurseries involved in these trials.

The use of prophylactic vancomycin in low doses reduces the incidence of nosocomial sepsis in the neonate. The methodologies of these studies may have contributed to the low rate of sepsis in the treated groups, as the blood cultures drawn from central lines may have failed to grow due to the low levels of vancomycin in the infusate. Although there is a theoretical concern regarding the development of resistant organisms with the administration of prophylactic antibiotic, there is insufficient evidence to ascertain the risks of development of vancomycin resistant organisms. Few clinically important benefits have been demonstrated for very low birth weight infants treated with prophylactic vancomycin. It therefore appears that routine prophylaxis with vancomycin should not be undertaken at present.